Question 1

When a brain-injured patient responds to nail bed pressure with internal rotation,adduction,and flexion of the arms,the nurse reports the response as

Accepted Answer

Internal rotation,adduction,and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized,it does not indicate localization of pain or flexion withdrawal.

Question 2

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

Accepted Answer

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure is elevated after surgery,furosemide or high-dose barbiturate therapy may be needed,but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries,and transfusion is usually not necessary.

Question 3

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

Accepted Answer

The patient with increased intracranial pressure (ICP)should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure,which increases ICP. Because the stimulation associated with nursing interventions increases ICP,clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Question 4

After having a craniectomy and left anterior fossae incision,a 64-yr-old patient has impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

Accepted Answer

ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak,clustering nursing activities may lead to more fatigue and weakness.

Question 5

The nurse has administered prescribed IV mannitol (Osmitrol)to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness?

Accepted Answer

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure,but these are not the best parameters for evaluation of the effectiveness of the drug. O₂saturation will not directly improve as a result of mannitol administration.

Question 6

An unconscious patient is admitted to the emergency department (ED)with a head injury. The patient's spouse and teenage children stay at the patient's side and ask many questions about the treatment being given. What action is best for the nurse to take?

Accepted Answer

The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support,but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

Question 7

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP)of 106/52 mm Hg and an intracranial pressure (ICP)of 14 mm Hg. Which action should the nurse take first?

Accepted Answer

Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] - ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] - Diastolic blood pressure [DBP]). Therefore the MAP is 70,and the CPP is 56 mm Hg,which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done,but they are not the first actions that the nurse should take.

Question 8

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have

Accepted Answer

The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

Question 9

When assessing a 53-yr-old patient with bacterial meningitis,the nurse obtains the following data. Which finding requires the most immediate intervention?

Accepted Answer

Shock is a serious complication of meningitis,and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature,but this is not as life threatening as the hypotension.

Question 10

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage,which action should the nurse take?

Accepted Answer

Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF)leakage. If the drainage is CSF,it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora,so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

Question 11

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

Accepted Answer

Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia,so the light should be dim.

Question 12

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

Accepted Answer

Meningococcal meningitis is spread by respiratory secretions,so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak,bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

Question 13

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

Accepted Answer

The Neisseria meningitides vaccination is recommended for children ages 11 and 12 years,unvaccinated teens entering high school,and college freshmen. Hand washing may help decrease the spread of bacteria,and good nutrition may increase resistance to infection. but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace,avoiding crowds is not realistic.

Question 14

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question?

Accepted Answer

Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient,elevating the head,and applying cold packs are appropriate orders.

Question 15

A patient with a head injury opens his eyes to verbal stimulation,curses when stimulated,and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as

Accepted Answer

The patient has scores of 3 for eye opening,3 for best verbal response,and 5 for best motor response.

Question 16

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation?

Accepted Answer

Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members' anxiety.

Question 17

Which statement by patient who is being discharged from the emergency department (ED)after a concussion indicates a need for intervention by the nurse?

Accepted Answer

After a head injury,the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

Question 18

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg,pulse of 110 beats/min,and of respirations 26 breaths/min. Which set of vital signs,if taken 1 hour later,will be of most concern to the nurse?

Accepted Answer

Systolic hypertension with widening pulse pressure,bradycardia,and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP)has increased,and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment,but they are not indicative of an immediately life-threatening process.

Question 19

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome?

Accepted Answer

Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

Question 20

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

Accepted Answer

A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI,hospital admission,and surgery are not usually indicated in a patient with a concussion.

Quiz 56: Acute Intracranial Problems